Actn Medica Scandinnvica. Vol. CXL, fwc. V, 1951.

Medical Studies in North Green-land 1945-1‘349. 111.

Allergic Diseases and Pulmonary Emphysema. BY

M. CH. EHRSTROMfl Helsingfors, Finland.

(Submitted for publication December 14, 1950.)

Allergy.

It is generally assumed. that about 10 per cent of Westerners have allergic ma- nifestations, while in about 50 per cent the results of intracutaneous tests with allergen (Eriksson-Lihr) are positive. The figure 0.5 per cent for the incidence of bronchial asthma is given by almost all the authors (Unger 1945, Jarvinen 1950).

In Greenland with a population of 22,000, there should thus be according to these figures, 2,200 patients with allergic diseases and 110 cases of bronchial asthma. However, judging by the literature there are no allergic diseases in Greenland. Bertelsen for instance (1940) writes: nRhinitis anaphylactica has not been observed so far in Greenland, probably owing to the air being almost free from dust (all the settlements are in the immediate neighbourhood of the sea and the majority of winds blow in and out of the fiords))). ))Nor have I found any cases of asthma as idiosyncratic reactions in Greenland)). - Allergic skin diseases are not mentioned either.

According to unverified information, a few cases of asthma were observed in 1947 in the colony Sukkertoppen in South Greenland.

The Author’s Own Investigations.

In theory, there should be 150 cases of allergic diseases, including about 7 cases of bronchial asthma in the district of Umanak with a population of 1,500. I found only 4 cases: one cases of Besnier’s prurigo in a woman with marked psycho-somat- tic neurosis (No. S), one case of eczema of the hands in a man with hemicrania (No.

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1 3frs Inga EhrstrBm, Majorsgstan 15, Stockholm. 21-511567. Acta med. Scandinau. V o l . CXL.

318 hi. CH. EHRSTROM.

l052), one case of urticaria (No. 888), and a typical case of bronchial asthma (No.

All the patients belonged to the part-trained group (See Part I1 of this series of papers), The patient with urticaria was a pure Eskimo and the others were all of mixed race.

The patient with bronchial asthma was the 21-year-old son of one of the chief superintendents. His features were distinctly European. He had had typical attacks for 18 months. None of the members of the family had had allergic manifestations. He reacted to intracutaneous tests as follows:

Extract of Greenland feathers

243).

weakly positive H )) dog’s hair )) ))

)) )) pollen ))

D R clothing ))

H )) dust from Danish houses negative

)) ) ) f i s h weakly positive D ) ) m e a t )) ))

)) H flour negative In addition to this patient, intracutaneous tests were made on 39 Greenlanders,

15 men and 24 women between the ages of 17 and 36. They all came from the Uma- nak colony. None of them had been in South Greenland or in Denmark, and none of them had had allergic manifestations.

The following extracts were used: dog’s hair, dust, pollen, meat, fish, cosmetics, flour, and feathers of Greenland birds. The extracts were kindly placed a t my disposal by Mr. Barfod, Pharmacist, Prihamnsapoteket, Copenhagen.

In about half, i. e. in 20 of the persons tested the reactions were completely negative. The following 19 positive reactions were obtained:

11 9 R.L. ............. 2 9 B.F . . . . . . . . . . . . . . 3 9 A.N. ............. 4 9 A.L. ............. 5 6 I.M. ............. 6 0 L.H. ............. 7 6 F.F. ............. 8 K.F. ............. 9 9 J.F. . . . . . . . . . . . . . .

10 9 D.F . . . . . . . . . . . . . . 11 E.A. . . . . . . . . . . . . . 12 9 J.D. .............. 13 9 K.P. . . . . . . . . . . . . . 14 9 A.M. ............. 15 9 J.H. . . . . . . . . . . . . . 16 6 N.T. ............. 17 9 A.F . . . . . . . . . . . . . . 18 6 L.T. ............. 19 3 H.H . . . . . . . . . . . . . .

- Dog’s hair

++ +++ ++ ++ +++ +++ + sv. + +++

-

-

- - -

sv. + ++ + -

-

Pollei

- Meat

=

Fish ~ Green- ~ o s - ~ land ~ Con- feathers trol netics ‘lour

I - - +-+ 1 + + + ~ -

1 - = negative; 8v . + = insignificant reaction; + = distinct weal ++ = large weal with slight erythema; + + + = large weal with erythema to 3 x 4 om.

MEDICAL GTUDIICS IN NORTH QREEKLAR’D 1048- 1949. 319

Comments.

The material is too small for statistical treatment but it is noteworthy that the Greenlanders of Umanak reacted positively to intracutaneous allergen tests in exactly as many instances (i. e. 50 per cent) as a civilized western population. They seem to be sensitive mainly to dog’s hair, fish and feathers with which they are in daily contact, but it is remarkable that there were 5 positive reactions to pollen extract in a country with such poor vegetation as Greenland.

The small number of cases with clinical allergic manifestations is in sharp con- trast to the extensive sensitization.

Discussion.

In a previous article of this series (11. Psycho-somatic neuroses) the question of the infrequency and origin of psycho-somatic neuroses in North Greenland was discussed.

Allergic manifestations itre syndromes which are closely related to the psycho- somatic neuroses. It may be difficult t o distinguish them from one another and naming the separate cases may be a matter of taste and depend on the importance attached to the sensitization present. The origin of allergic manifestations and psycho-somatic neuroses are very similar. The same problems - as to the signif- icance of constitutional factors on the one hand and environment on the other - call for a definite solution.

Since I found only 4 cases of allergic diseases, statistical comparisons cannot be made between these and the cases of psycho-somatic neurosis. Three patients were of mixed race and one was a pure Eskimo. Racial characteristics are thus probably of no importance in this connection. All 4 patients belonged to the part-trained group. No significant conclusions can be drawn on the basis of this fact, but the similarity with the incidence of psycho-somatic neuroses is striking. One is inclined to believe that - as with the psycho-somatic neuroses - it is not necessary t o attribute primary importance to constitutional factors. In the manifestation of allergy environmental factors similar to those in psycho-somatic neurosis may play a part.

Pulmonary Emphysema.

In the discussion of the etiology of pulmonary emphysema the question of the rSle of constitutional factors has always taken a prominent place. The theory that true pulmonary emphysema is due to hereditary ())constitutional))) weakness of the elastic tissue of the lungs has been widely supported, but never proved. However, it is also claimed that pulrnonary emphysema, both ))true)) and ))secondary)), follow- ing, for instance, chronic asthma may be explained without recource to consti- tutional factors. Hans Heckscher, among others, considers the irreversible, pul- monary emphysema as the final stage of a series of (pathological) changes brought about by functional factors.

320 M. CII. EMRSTROM.

dccording to Heckscher incipient true pulmonary emphysema is pathogenetically built up of the triade: a) a changed type of respiration (of the costal type), b) a changed static work by the respiratory muscles (changed posture), and c) a shift in the level of respiration (dilatation of lungs).

The following factors influence the etiology: a) cough due to affections in the upper respiratory tract, bronchitis, tuberculosis, etc., b) cardiac neurosis and respiratory neurosis with mimic tension of the static muscles and contraction of the diaphragm, c) adiposity and other conditions which cause a round-shouldered posture, d) acquired ,military)r carriage, e) blocked nasal respiration, f ) occupational dyspnoea in disorders of the heart or exhausting exertion, g) malformations of the thorax, asthenic kypho-lordotic carriage, trau- matic or other thoracic lesions with fixation of the chest due to pain.

Since bronchial asthma as an etiological factor in pulmonary emphysema does not occur in North Greenland, conditions there are very favourable for studies of the problems connected with emphysema, especially those which are mentioned by Heckscher.

I have not observed the occurrence of true pulmonary emphysema in Greenland- ers or other primitive peoples mentioned in the literature. Bertelsen told me per- sonally that he found compensatory emphysema in tuberculous patients and iso- lated cases of senile emphysema but he does not recollect having found any cases of true (substantial) emphysema because his attention was not specially directed to this disease.

The Author's Own Investigations.

All adults were examined, special interest being attached to pulmonary emphyse- ma. Dyspnoea, characteristic of pulmonary emphysema, in the past history or objectively, was noted in particular, as also was the configuration of the thorax, type of breathing, chronic bronchitis and pulmonary dilatation revealed by stethos- copy or X-ray examination. About 300 cases were examined by X-ray.

Two cases of senile pulmonary emphysema (Nos. 410, 651) and some cases of compensatory emphysema in pulmonary tuberculosis were found. No dilatation of the lungs was observed in the patient with bronchial asthma. On the other hand, in a 45-year-old pure Eskimo woman acute pulmonary congestion was found in connection with infection of the respiratory tubes of the bronchiolitis type.

N o cases were found which might be characterized as the sequel to chronic bronchitis or a s true pulmonary emphysema.

Discussion.

Since I found no definite cases of pulmonary emphysema among 1,300 individuals and as Bertelsen, with 40 years' experience, cannot recollect having observed this syndrome, which is so striking in typical cases, we are entitled to suppose that the combination of factors required for the development of pulmonary em- physema occurs very rarely in North Greenland.

The great incidence o f pulmonary emphysema among people of the western civilizations is largely due to bronchial asthma. This disease, as already mentioned.

MEDICAL STUDIES IX NORTH QREENL.4NIJ 1948-1049. 32 1

does not appear in North Greenland. Other factors that may be active in the development of pulmonary emphysema, are found here, one of them being cough. About 15 per cent of the Umanak population suffer from pulmonary tuberculosis (Bertelsen). Annual epidemics of respiratory infections, with or without bronchitis, occur. Almost the entire population is affected. The investigations showed that 358 or one-third of the people examined were especially inclined to catarrhal infec- tions. Among these, 103 cases might be termed relapse or chronic bronchitis.

Another factor mentioned in connection with the etiology of emphysema is efixation of the chest due t o pain)). The Greenlanders often complained of ))stitches)) in the chest, and there is a special word in their language for it, k a p o r t o q, which probably means sensation of pain with ))myalgic)) origin, irritation of the pleura (tuberculosis), catarrh of the respiratory passages and, possibly, neurotic sensations connected with the fear of contracting pulmonary tuberculosis.

However, conditions in Greenland show that neither cough, with or without bronchitis, or pain in the chest alone suffice t o cause pulmonary emphysema. What factor or factors are then necessary? The reply is: hereditary constitutional factors (viz. reduced elasticity of the lungs, abnormal body structure) on the one hand, and on the other the environmental factors as mentioned by Heckscher.

Regarding the latter i t should be noted that adipositas is rare, acquired ))mili- taryo posture does not occur, and the factors ))blocked nasal respiration)) and BOC

cupational dyspnoeao are not the same in Greenland as in Europe. Furthermore, Heckscher states that the ))neurotic)) factor is of importance. He

states that in cardiac and respiratory neurosis (according to my nomenclature psycho-somatic neurosis) ))mimic)) tension of the static muscles and contraction of the diaphragm promotes the development of pulmonary emphysema.

Whether this view i s correct or not, the rare occurTence of emphysema in North Greenland may be related to the rare occurrence of psycho-somatic neuroses.

As already mentioned, hereditary constitutional factors may also play a part. In Section I, General Introduction, I mentioned that about one-third of the

population of the Umanak district were pure Eskimos, while the remainder were frequently very much mixed with Europeans, mainly Danes. Characteristics of the pure Eskimo are: short stature, short thorax with gracile, ))Childish)) ribs, wide (often almost straight) epigastric angle and loose abdominal coverings. The mobil- ity of the joints is great; for instance, the women washed skins a t the edge of a hole in the ice standing with their knees straight like a folded clasp-knife. The long tube bones were remarkably slender and in the twenty-year-olds the aorta was roent- genologically like that of a European child of ten. One got the impression of a ))general fragility of the mesenchymal tissue)). These people might be characterized as most like youthful pylmics.

This refers to (at most) only one-third of the population. In the great majority - certainly more than two-thirds - the build was similar to that of Europeans. There were many who were over 180 cm tall and typical leptosomes were common. Among these there were also some with malformatiolzs of the thorax and asthenic hypho-lordotic posture.

These ))mesenchymal characteristics)) may, almost certainly be termed hereditary

322 &I. CII. E I I R S T R ~ M .

constitutional and were in the greater part of the population similar to those of Europeans. If there exists a hereditary predisposition to pulmonary emphysema (for instance, hereditary characteristics in the elastic tissue of the lungs, physical structure, shape of thorax, special characteristics of the ribs, cartilage and arti- culations) then the majority of the people in Umanak would be predisposed to the condition. It seems improbable that these hereditary factors which promote pulmonary emphysema would be so specific, so independent of the structural characteristics of the body already mentioned that they alone would be inherited. It is difficult however to believe that hereditary factors predisposing to pulmonary emphysema - if they exist - would not occur in a population mixed with Europeans to such an extent and over so many years (more than 250 years) as the North Greenlanders. T h i s investigation has given 120 definite answer to the questiori regurding the r d e of hereditary factors in the etiology of pulmonary emphysema. The absence of emphysema, in spite of favourable constitutional factors being found, seems to be a point in favour of these factors being of secondary importance.

The discussion of pulmonary emphysema thus seems to result in the conclusion that the evident rarity of this disease in North Greenland may be attributed to special factors and combinations of factors. The fact that Bronchial asthma hardly ever appears as an etiological factor is of very great significance. The in- fluence of other factors is more difficult to assess, but the investigation seems to show that possible hereditary constitutional factors are not dominant and that the infrequent occurrence of pulmonary emphysema in North Greenland may be related to the rare occurrence of psycho-somatic neuroses.

Conclusions.

1. Allergic manifestations are rare among Greenlanders in the Umanak district of North Greenland in spite of sensitization there being about equal to that in people of the western part of the civilized world.

2 . All allergic patients (4) belonged to the part-trained group, 3 of them being of mixed race and one a pure Eskimo.

3. No definite conclusions can be drawn since the number of cases is small. But, as allergic manifestations represent a complex of symptoms closely related to psycho-somatic neuroses, and as the results of the examinations in both disease groups were practically analogous, the following observations may be used as the basis for further investigations:

a) Racial characteristics do not seem to play an important part in the incidence of allergic manifestations.

b) There is no reason to attribute a dominant r81e to constitutional factors. c) Among the factors which may influence the incidence of psychosomatic neu-

The western mush of life)), the individual’s level of intelligence, degree of know-

4. Substantial pulmonary emphysema is evidently uncommon in North Green-

roses the following may be active in the genesis of allergic manifestations:

ledge, linguistic forms of expression and emotional life.

land.

MEDICAL S’IUDIES IN KORTH QREERLAND 1048-1949. 323

5. It is noteworthy tha t bronchial asthma very seldom occurs among the etio- logical factors.

6. The influence of other factors is more difficult t o assess (cough, caused by infections of the respiratory passages, bronchitis, pulmonary tuberculosis, etc.) but the examinations seem t o show tha t hereditary constitutional factors - if they exist - are not of primary importance, and t h a t the rare occurrence of pul- monary emphysema may be related t o the infrequent occurrence of psycho-somatic neuroses.

References.

Bertelsen, A.: Gronlands medicinsk statistik 06 nosografi. Meddelelser om Gronland 117. - Bertelsen, A.: Persoiial communication. - Heckscher, H.: Acta Med. Scand. 120 349 (1945). - Jarvinen, K. A. J.: Annal. Med. Int. Fenniae. (1950). - Unger, L.: Bron- chial Asthma. Baltimore 1945.

Case reports in Swedish are deposited a t the Library of the University of Helsingfors.